Enrolled Family Form

St. Philip ECC Emergency Form 2018-19 SY

Child's Information
Please complete the following sections prior to your child attending their first day of school.
Name
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Please complete the section below. If your child has a preferred "nick name" please add that after the complete spelling of his or her first name.
Date of Birth //
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Sex
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Child's Home Address
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Phone Number to Call first -- ext
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Name of person to call first:
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Official School Email for Communication
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Previous School/ Daycare Attended
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Other Schools's your Child is Attending
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Person (s) or Agency Having Legal Custody of Child
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If both parents have joint legal custody please type, both parents. If there is a custody agreement, please type who has primary legal custody. All custody documents must be given to the school office.
Mother's Name
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Mother's Marital Status
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Mother's Home Phone --
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Mother's email address
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Mother's Home Address
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Mother's Place of Employment
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Mother's Work Phone -- ext
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Other Phone for Mother -- ext
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Father's Name
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Father's Marital Status
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Father's Home Phone --
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Father's Email Address
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Father's Home Address
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Father's Place of Employment
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Father's Work Phone -- ext
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Other Phone for Father -- ext
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Names of Siblings Living at Home
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Please list all siblings living in the home with the child.
Child's Physician
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Physician's Phone Number -- ext
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List any Allergies or Intolerance to food, medication, etc.
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Describe the action to be taken if an allergy, intolerance, etc. occurs
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1st: Emergency Contacts: In case parents or guardians are not available
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Please list two emergency contacts. One may be out of state but one must be in the state of Virginia
Emergency Contact #1 Address
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Emergency Contact #1 Phone -- ext
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Emergency Contact #1 Phone #2 -- ext
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2nd Emergency Contact
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Emergency Contact #2 Address
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Emergency Contact #2 Phone -- ext
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Emergency Contact #2 Phone #2 -- ext
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Authorized Pick Up: Who is authorized to pick up your child?
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Please list parent name.
Authorized Pick Up: Who is authorized to pick up your child?
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Parents must be listed
Authorized Pick Up: Who is authorized to pick up your child?
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Please list Emergency Contact
Authorized Pick Up: Who is authorized to pick up your child?
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Please List Emergency Contact.
Authorized Pick Up: Who is authorized to pick up your child?
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please list anyone else who might need to pick up your child
Authorized Pick Up: Who is authorized to pick up your child?
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please list anyone else who might need to pick up your child
Authorized Pick Up: Who is authorized to pick up your child?
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please list anyone else who might need to pick up your child
Person (s) NOT authorized to pick up my child from school.
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Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
Parent or Guardian Agreement I agree to notify the school within 24 hours if my child or any member of my immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, my emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, which a physician deems necessary fro the well-being of my child.
Parent or Guardian Agreement
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General Information
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Does he or she require daily medication?
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Does your child have a medical condition we should know about?
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Signature
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Please print your name below agreeing that all information is correct.
Notice: All information requested on registration is required by the Department of Social Services under the 22 VAC 13-30-80. Code
Handbook Agreement Form
I have read the current copy of the Parent/Student Handbook. In doing so, I have explained the content of this document to my student/s. I acknowledge and agree to the policies contained therein, and will, require my student/s to comply with the policies.
Name
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Date //
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On line signature: Please type your name below
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